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Questionnaire
We ask first-time visitors to our clinic to fill out a medical questionnaire.
The personal information you provide will not be used for any purpose other than for medical
treatment.

Full name Date of Entry Year Month Date

name Name <Accompanying Person None

Yes (with whom?) Yes (with whom) (with whom)

When and if so, what are your symptoms? Please be specific.

from when

when (emphatic)

What kind of symptoms < Example: difficulty sleeping, mood swings, anxiety, irritability, headaches...etc.

(i)
(2)
(iii)
➃
5)
Please describe any causes or triggers of symptoms that you can think of.
< Home, school, work, etc. Do you have any idea about stress in your living environment and relationships? >

Have you ever visited a psychosomatic, psychiatric, or neurological doctor?

not (verb-negating suffix; may indicate question or invitation with rising intonation) Yes Yes ＜ If you have a
letter of referral, please submit it to the receptionist.

(1) Year Year Year Year Month Where

(2) Year Year From Year Month Where

Have you ever suffered from any physical illnesses?

No Yes/ No ＜ Treated or currently undergoing treatment

(1) Name of disease Age Name of medical institution
(2) Name of disease Age Name of medical institution

Have you ever been diagnosed with heart disease or had an abnormal ECG indicated in a medical
checkup?
No Yes/ No ＜ Treated or currently undergoing treatment
(1) Name of disease Age Name of medical institution

Are you currently taking any medications? ＜ (If you have a medication book, you do not need to fill in
this form.
No / Yes
Yes < Name of drug: ＞
Please describe your current situation or circle all that apply.

Height cm Weight kg < weight loss/kg No change

Diet Times/day Appetite Yes / No No appetite

Drinking Habit None Smoking habit None / Yes Yes / No ＜

since age How many cigarettes/day

Allergies None Yes / No Yes ＜ What is your allergy?

＞Menstruation (Female only) Steady Irregular

Irregular Stopping Stopped Stopped Pregnant

Do you have psychological symptoms such as severe irritability or depression before menstruation? No / No
Yes/No

Let me ask you about your recent sleep situation.

Bedtime Hour minutes Wake-up Time Hour minutes

Sleep status ＜ Insomnia ・ Poor sleeping habit ・ Waking up in the middle of the night ・ Waking up early in
the morning ・ Unable to wake up in the morning

We will ask you about your and your family's situation.

Are you married? Married Married Never married

Do you have siblings? Yes. Number 2 out of 3 No
Who do you live with now? ＜I am a member of the family. ＞I
am...
Have any of your family members or relatives seen a psychosomatic or psychiatric
doctor? No, I have not. Yes/No Yes, they have.
(Relationship: (Name of disease: ) has been visiting the hospital for (Name of disease: ) / is in the
hospital
(Relationship: (Name of disease: ) has been visiting the hospital for (Name of disease: ) / is in the
hospital
I would like to ask you about your last education and work experience.

Last education ＜> Graduation

career Career Currently <Job Title: ＞I have

been working at ＞Year

Past (1) <Job Title: > for < >Year

Past (2) <Job Title: < >Year
Past (3) <Job title: < >Year

Please read the following items and tick ✓ if you agree with them.

○ The clinic will be under the primary care physician system.

In principle, the physician who has examined you at your first visit will be your primary physician. Please
make an appointment for your next and subsequent consultations on the day of your primary doctor's
outpatient consultation.

○ Our clinic is by appointment only.

However, depending on the situation, we may not be able to see you on time for your appointment. Please
understand this in advance. If you need to cancel or change your appointment, please contact us in
advance.

○ When it is judged that the hospital is affecting other patients and our medical services due to abusive
language, violence, intimidating behavior, etc.
Please note that we may refuse to provide medical treatment in the following cases
○ Those who use affiliated parking lots will receive a service ticket for the waiting time.
○ If you forget to bring your insurance card at the beginning of the month, you will be charged for the
cost of the service. The difference will be refunded to you at a later date upon confirmation of your
insurance card.
○ When providing patient information in writing, please understand in advance that if the information is not
covered by insurance (e.g., information provided to an industrial physician), it will be at your own
expense.

○ Please refer to the next page for our privacy policy.